Powerful Medicine; a dimension of the Nassar case

I want to start this post with a really clear content notice; if you’re uncomfortable with or likely to be triggered by descriptions of sexual assault, you may want to gird yourself or take a pass on this post entirely. I experienced nausea myself in reading the accounts, but I don’t think it is really possible for me to get to the most important points of this post without some level of detail in the description.

I’m not going to talk about any of that; not because I don’t regard it as important (it definitely is important), but rather because there is something else that so many accounts of this discussion miss. It is something that we see in theoretical discussions in bioethics, and is deeply important for addressing and preventing many future predators like Nassar.

“[Dr. William Strampel, who has since resigned as dean of Michigan State’s College of Osteopathic Medicine, Nassar’s then-employer] was at home when he received a call telling him that a student had accused Nassar of assaulting her, massaging her breasts and vaginal area when she visited him for a hip injury. The day of her one and only appointment with Nassar, the woman told a receptionist and another doctor at the sports medicine clinic she “felt violated.” Strampel told the detectives he suspended Nassar from seeing patients indefinitely the following afternoon and let law enforcement and the school’s Title IX office take over from there.

The university’s police department opened a criminal investigation. The university’s Title IX department interview four experts to evaluate the complaint, all of whom had ties to Nassar.

Among the four was Dr. Brooke Lemmen, a fellow physician who was viewed by colleages as a close friend and “protege” of Nassar’s. She told the Title IX investigators in the spring of 2014 there was nothing sexual about the treatment Nassar administered. The other three experts agreed with her opinion and decided that the complainant didn’t understand the “nuanced different” between medical procedure and assault.

Lemmen resigned under pressure last January. She faced allegations that she had failed to tell her bosses that Nassar had told her–in 2015–he was being investigated by USA Gymnastics for suspected abuse… She was also accused of removing some of Nassar’s patient files from the sports clinic after he was fired by MSU in 2016.”

There are two features of this that stand out from the standpoint of medical ethics. Setting aside that the Title IX investigators were too incompetent or indifferent to concern themselves with finding an unbiased expert, four experts gave the opinion that a massage of the breasts and vagina were appropriate treatment for a hip strain.

Some have noted that Nassar was a practitioner of osteopathic medicine, which differs in many respects from standard medical practice. (I’ll come back to this point in a bit.) I’m not as familiar with the standards of osteopathic medicine as with standard procedures; some diagnoses for hip pain might involve some cursory massage, but it is unlikely that direct massage of the vagina (as the patient describes) would be appropriate and it is totally implausible (so far as I can tell from some research) that it would be appropriate to massage the breasts. (The only listed exception I’ve been able to find is in the case of certain effects of pregnancy; the patient wasn’t pregnant.) And, in either case, the fact that Nassar’s approach was to administer this without clearly outlining this with the patient shows a clear disregard for best practices in consent.

How is it that the experts who were asked to review this case have not been subject to their own review in virtue of their bad judgment? Perhaps they simply failed once in their judgment (though, given the circumstances of Lemmen’s resignation, that is unlikely), but this still seems like a reason to raise concerns over their various practices.

From the mid-90s until Nassar’s arrest, there were a number of professionals that looked at the standards for his “exams” and decided that it was not criminal. There will, and should be, criticism directed at the institutional failures within the major organizations, but there hasn’t been much on the failures of medical professionals to raise concerns about Nassar’s “practice,” and this is damning of either the competence or ethics of those professionals. (And, whether they were incompetent or unethical in their handling is not an especially important difference in sight of the fact that many continue to practice.)

This opens a question of professional ethics: what are the obligations of medical professionals to pay attention to the behavior and practice of their colleagues? What are the consequences for failing to pay adequate attention, or prevent harm in those circumstances?

The exact strength and scope of these questions are complicated, to be sure, but there surely should be some expectation here.

At the risk of sowing some confusion (and trying immediately to clear it up) the French theorist Michel Foucault writes in The Birth of the Clinic (see the end of Ch. 3; emphasis in original):

It is often thought that the clinic originates in that free garden where, by common consent, doctor and patient met, where observation took place, innocent of theories, by the unaided brightness of the gaze, where, from master to discipline, experience was transmitted beneath the level of words. And to the advantage of a historical view that relates the fecundity of the clinic to a science, political, and economic liberalism, one forgets that for years it was the ideological theme that prevented the organization of clinical medicine.

It is not merely that, as a historical fact, medical practice has developed through and dependent on the power relations between the doctor and patient; the doctor has the power to heal the patient, and therefore power over the patient. It is also that the asymmetry of this power relations brings about a freedom of the doctor to do what they regard as best, often with relatively limited input from the patient. (The movement towards informed consent is fairly recent and, unfortunately, the ability of patients to confer informed consent is limited both by the background information accessible to the patient and the ability of the physician to communicate to, and thereby adequately inform, the patient.)

After all,

the complainant didn’t understand the “nuanced different” between medical procedure and assault.

At various points in his practice, Nassar violated best standards and practices in consent and hygiene; these assaults resulted in vaginal bacterial infection and pneumonia for at least one patient, and vaginal tearing for many others. And yet, various complains to this effect were set aside on account of the expertise and standards of “the good doctor.” (Characterized by the results perceived by his superiors at MSU and USA Gymnastics, not by his patients.) And this is the problem.

I cannot help but wonder (or rather, assume) that most of the physician sexual assault cases involve male doctors and female victims. If that is the reality, then one must consider not only the power dynamic between physician and patient, but also between men and women. This web then gets tangled up in cultural and social systems that encourage and allow such things to happen.

As a result, this puts male medical professionals at a disadvantage—especially when it comes to working with women in sensitive situations (e.g., Pap tests). Surely, not all male nurses or doctors are predators, and so those that are not may feel restricted in their line of work with what they can and cannot do. They may be fully capable of performing a particular exam or duty, but may choose not to, or have a female professional execute it, or worry about how their actions may be interpreted even if they are adhering to strict professional code—simply because of their sex. And then cases like Nassar just destroy trust and confidence in male medical professionals altogether. It becomes difficult to tease apart ethics from gender from social norms from power.

Excellent points. I’d add that it puts women at a disadvantage as well, forcing them to do all of these tests for their male colleagues can add to their workload in a way that does not add to the male workload.